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Health and care providers in Bristol, South Gloucestershire and North Somerset are investing an extra £4.3 million in local community healthcare services to help people avoid unnecessary hospital stays and return home sooner following a short hospital admission.

As part of the plans community healthcare services provided by Bristol Community Health (BCH), Sirona care & health and North Somerset Community Partnership (NSCP) will be expanded to support enhanced admission avoidances and discharge measures.

The measures aim to improve care for individuals while also helping local hospitals to manage bed occupancy rates during times of high demand such as over the winter months.

The funding will be used to expand the Rapid Assessment Emergency Care Team (REACT) provided by BCH to work in the Bristol Royal Infirmary and Southmead Hospitals to assess people arriving in A&E and if possible to refer them immediately into community healthcare services in order to prevent the deterioration that can lead to an emergency hospital admission.

REACT currently operates five days per week but from October this will be expanded to a seven-day-a-week service operating at both hospitals in Bristol.

Once individuals have been identified they will be referred to Rapid Response services operated by BCH, Sirona and NSCP to help people avoid hospital admissions. The Rapid service provides targeted clinical care to patients in their own homes in order to prevent the deterioration that can lead to an emergency admission.

The REACT and Rapid Response Services provided by BCH, Sirona and NSCP already help to avoid thousands of hospital admissions each year and it is hoped by expanding the services, a further five to 15 admissions/discharges per day will be achieved from A&E departments at the BRI and Southmead Hospital.

The three community healthcare providers are also working with Southmead Hospital, the BRI, Weston General Hospital and the three local authorities to streamline the process of moving people out of hospital when they have recovered, and ‘join up’ the care they receive following discharge.

Previously, when a person was medically well enough to leave hospital, ward staff would work with them to assess their ongoing care needs and identify care solutions.

But from the start of October, as part of the changes co-ordinated by Sirona on behalf of health and social care, ward staff will be able to complete a single referral form for each individual describing what care is needed.

This will then be sent to a specialist ‘navigator’ team, based in each hospital and made up of a social work practitioner, qualified therapist and community health manager, who will meet on a daily basis to identify the best solution for each patient and prepare a tailor-made package of care for them.

As well as improving care for people, the new system will also stop duplication of effort between hospital and community healthcare staff, which can lead to unnecessary delays in discharges.

The project is part of plans for an Integrated Care Bureau which in the long term will provide a single point of access for GPs and community practitioners to refer patients and be advised of the most appropriate services available.

Local GP and clinical lead for acute care at Bristol, North Somerset and South Gloucestershire CCG, Dr Lesley Ward, said: “These measures are a great example of our whole health and care system, including hospitals, community providers and local authorities, improving care for patients by working together to tackle the challenges of avoidable hospital admissions and unnecessary delayed discharges.

“As a GP, I know that people who no longer need treatment in a hospital recover much better the sooner they are able to get home and receive care in the community.

“By helping people to stay out of hospital or to leave, with the right care, once they are fit to go, we will be delivering clinical benefits for patients as well as helping our busy hospitals to manage their bed occupancy rates during periods of high demand.”

Jenny Theed, Sirona’s Director of Nursing and Operations and Senior Responsible Officer for the phase one of the Integrated Care Bureau initiative, said: “We wanted to make sure patient needs were at the centre of what we do and fit services to them rather than the person fitting the services. Therefore, from 1st October, ward staff will refer people to a dedicated navigation team made up of staff from across health and social care who will ensure the patient has the right care at the right time in the right place within the community. This will shave days off an individual’s stay in hospital.

“People with very complex needs can be cared for in the community and we know home is best for people completing their recovery and this may mean daily or weekly support in the home or transfer to a community rehabilitation unit bed first.

“To achieve this, we needed to look at all the existing systems and we discovered that across the region people were spending longer in hospital than they needed to due to the historic processes which were in place. There were also occasions when a patient was referred from hospital twice – to community health professionals and to social care teams which was leading to a duplication of work and delays when suggested solutions weren’t right for the individual.

“It is a ground breaking process as it is transforming systems which have been in place for years, is joining up health and social care providers and together this will hugely improve the experience of patients who need help with remobilising or regaining skills after an accident or illness or who may need support in the home to help them regain their independence.”

The service enhancements are being taken forward as part of Healthier Together, the Bristol, North Somerset and South Gloucestershire Sustainability and Transformation partnership of 13 local health and care organisations.

Healthier Together represents a commitment to improving health and care in Bristol, North Somerset and South Gloucestershire. It is about tackling the issues that matter most and finding ways to continue providing safe, high-quality care for generations to come.